Emergency Docs Are Overwhelmed

Something must be done, says Edwin Leap, MD

I was working a 6 p.m. to 2 a.m. locums shift a few months ago and was preparing to leave. There were about 15 patients in rooms and 15 waiting to come back. I asked the lone night physician: "Hey, do you want me to stay a while?"

I packed my bag and headed to the hotel, still feeling guilty but also exhausted. And wondering why my colleagues are treated so poorly in emergency departments all over the land.

I see it time and time again. Overwhelming numbers of patients with increasingly complex medical and social problems, versus inadequate physician coverage at all hours of the day, and especially the night. We've all done it. Already fatigued, we have five chest pains yet to see, as well as a trauma on the way into the department. Two more patients have fever but don't speak English, and we're waiting to make the translation line work. And there's a large facial laceration yet to be repaired. And that's just the first nine patients. It's not even 3 hours into the shift. (And the EMR backup is in process.)

Do we call the cardiologist and internist to take over the chest pain, ask the surgeon to come and check the trauma, and get plastics to close the face? Hardly. Furthermore, that's just more time arguing on the phone. It's easier to forge ahead as wait times creep from 2 to 4 to 8 hours. Furthermore, on days it's the same; with the added gift of acting as backup for all of the primary care offices.

There was a time when we actually might have asked other staff members to help. Those times are mostly gone. As a specialty, we've spent decades saying, "Don't worry, we'll take care of it!" And our fellow physicians have obliged.

But at least, when we're alone and overwhelmed, we don't have to worry about lawsuits, patient satisfaction, quality measures, charting, coding, door to needle times, door to CT times, door to doctor times, door to ... oh, yeah, we do have to worry about those things. As well as the sound criticism that will follow in the light of day, when all the administrators and other specialties are rested and shocked (shocked I say!) at how things went when we were alone.

The thing is, hospitals get a real bargain out of the understaffed emergency department. The physician does a heroic job of seeing every conceivable complaint and doing it with knowledge, skill, professionalism, urgency and political savvy. If you think of what they bill for that 35-patient, single-coverage shift versus what they pay the exhausted physician, it's a "win-win for old admin!"

In fact, emergency department physicians do the work of several people throughout their shifts, from secretary (filling out forms and entering orders), to social worker, from surgeon to psychologist, pediatrician to hospice worker. And we do it while trying our best to keep up with ever more complex charting rules, treatment pathways, and admission battles.

We also do it when expectations are ridiculous. For instance, why should we, in a busy urban department, be doing the full stroke assessment when a neurologist could be at the bedside? Why are we arguing about the NSTEMI patient, or managing complex rhythms, when cardiologists (the alleged experts) are available? Why am I doing the neonatal sepsis workup in all the chaos when a pediatrician could come to see the child?

And partly because we simply agreed. Consequently, "call me when the workup is complete" is a common mantra in the ED, where we are indeed interns for life.

I wonder, are we training our bright-eyed residents for this in the trauma center, in the simulation lab? Because when they leave the medical center for the community, this is how it looks. All the exciting, cool stuff. But "all by your lonesome."

I know that lots of jobs are hard. I get that. But from what I've seen, all too many emergency departments over the past few years are miserable, and dangerous, working environments. Does OSHA ever even look at our workplaces? Because when JCAHO does, they just increase the workload in the alleged interest of patient safety (and their own job security).

We should all be proud of what we do. But we shouldn't be abused children, or Stockholm Syndrome hostages to inadequate conditions. We should be treated as valued professionals. And if there aren't enough other doctors to go around, every effort should be made to help and encourage those willing to work in such daunting settings.

And until you've come to work a shift alone, with a full waiting room and 10 potentially critical patients right up front, you don't understand what it's like on the ground. And you have no grounds to criticize anyone facing the same tsunami of expectations and exhaustion in the noble effort to save life and limb, and ease suffering.

In the end, the weary look in the eyes of my colleagues breaks my heart. And something has to be done.

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